Healthcare Provider Details

I. General information

NPI: 1811423189
Provider Name (Legal Business Name): SPORTS REHAB LA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2017
Last Update Date: 08/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16200 VENTURA BLVD #201
ENCINO CA
91436-2205
US

IV. Provider business mailing address

16200 VENTURA BLVD #201
ENCINO CA
91436-2205
US

V. Phone/Fax

Practice location:
  • Phone: 818-986-1203
  • Fax: 951-272-9924
Mailing address:
  • Phone: 818-986-1203
  • Fax: 951-272-9924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code111NR0200X
TaxonomyRadiology Chiropractor
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PATRICK KHAZIRAN
Title or Position: PRESIDENT
Credential: D.C.
Phone: 818-986-1203